[The importance of a developmental approach in psychiatric assessment and treatment of adults with intellectual disability]. / Die Bedeutung des emotionalen Entwicklungsniveaus bei der psychiatrischen Behandlung von Menschen mit geistiger Behinderung.

INTRODUCTION: Mental disorders are 3-4 times more frequent in individuals with intellectual disabilities than in those without. From a developmental perspective the reason for this high prevalence could be, besides biological aberrations, a personality development with a difference between cognitive and emotional developmental levels. This discrepancy renders the person being highly vulnerable for the onset of problem behaviour and psychiatric disorders. For a proper insight into processes which have led to the disorder, it is necessary to evaluate the level of emotional development. This can be determined by the "schema of emotional development (SEO)" developed by A. Dosen. METHODS: By means of a case description the authors demonstrate the application of SEO in the assessment and utilization of the concept of the level of emotional development in clinical practice. RESULTS: The knowledge of the level of emotional development contributes to the explaining and understanding of the disorder, and also facilitates the establishment of an integrated diagnosis and the creation of appropriate integrated treatment strategies. Hence, temper tantrums, sleep patterns and mood improved in the case described. CONCLUSION: Besides biopsychosocial aspects, the developmental aspect, and in particular the level of emotional development should be taken into consideration in the diagnostic work-up and treatment of individuals with intellectual disabilities and mental health problems. The data generated by the SEO may help in understanding the disorder and developing a treatment approach for these individuals.

Depression in Down syndrome: a review of the literature.

BACKGROUND: Depression has been frequently reported in individuals with Down Syndrome (DS). The aim of this article is to provide a comprehensive, critical review of the clinically relevant literature concerning depression in DS, with a focus on epidemiology, potential risk factors, diagnosis, course characteristics and treatment. METHODS: We searched the PUBMED database (January 2011) using the keywords ("Depressive Disorder [MESH]" OR "Depression [MESH]" OR "depress* [All Fields]") AND ("Down Syndrome [MESH]" OR "Down syndrome [All Fields]" OR "Down's syndrome [All Fields]"). Review articles not adding new information, single case reports and papers focusing on subjects other than depression in DS were excluded. RESULTS: The PUBMED search resulted in 390 articles, of which 30 articles were finally included. Recent information does not support earlier suggestions of an increased prevalence of depression in DS compared to other causes of Intellectual Disability (ID). However, individuals with DS show many vulnerabilities and are exposed to high levels of stressors that could confer an increased risk for the development of depression. Apart from general risk factors, several potential risk factors are more specific for DS, including smaller hippocampal volumes, certain changes in neurotransmitter systems, deficits in language and working memory, attachment behaviours and frequently occurring somatic disorders. Protective factors might play a role in reducing the vulnerability to depression. The diagnosis of depression in DS is mainly based upon observable characteristics, and therefore, the use of modified diagnostic criteria is advised. Although several common treatments, including antidepressants, electroconvulsive therapy and psychotherapy seem effective, there is evidence of undertreatment of depression in DS. CONCLUSIONS: There are important limitations to our current clinical knowledge of depression in DS. Future studies should include systematic evaluations of pharmacotherapeutic and psychotherapeutic interventions.

Atomic force spectroscopy evidence of non-specific adhesion of Aggregatibacter actinomycetemcomitans.

Aggregatibacter actinomycetemcomitans is a gram-negative periodontopathogen found within the subgingival plaque on the tooth surface. It is associated with localized aggressive periodontitis, a severe form of periodontitis in adolescents, and is the cause various extra-oral infections. The ability of this organism to tenaciously adhere to abiotic surfaces has been attributed to bundle-forming type IVb-like fimbriae whose major component is the fimbrial lower molecular weight protein (Flp). In this study the adhesion of purified Flp fimbriae isolated from A. actinomycetemcomitans to materials with different surface chemistries was measured using atomic force microscopy (AFM). The adhesion of Flp fimbriae to uncoated and saliva-coated tooth, hydroxylapatite, and glass surfaces was compared. Force data were used to quantify the magnitude of adhesion of the fimbriae and force-distance profiles were used to predict the mechanisms of adhesion. The results of this study confirm that non-specific interactions likely dominate the adhesion of these fimbriae to the surfaces used in this study. However, force data indicate that non-specific electrostatic interactions may be more significant under the conditions used in this study. Salivary coatings did affect both the hydrophobicity and adhesion of these fimbriae to the surfaces used in this study. Additionally, these data demonstrate the affect of salivary proteins on bacterial adhesion in the oral cavity.

Integrative treatment in persons with intellectual disability and mental health problems.

BACKGROUND: Clinical experience has proven thus far that a monodisciplinary treatment approach to behavioural and psychiatric problems in persons with intellectual disability (ID), such as psychotropic medication or behaviour modification programmes, has yielded limited success. It is clear that the complexity of behavioural and psychiatric problems in this population calls for a treatment approach from different perspectives. METHODS: A multidimensional treatment approach to the persons with ID who suffer from behaviour problems and psychiatric disorders is described. RESULTS: Four dimensions - biological, psychological, social and developmental - are represented as well in an integrative diagnosis as in an integrative treatment, embodied by cooperation of different professionals, such as a psychiatrist, psychologist, pedagogues, social worker, nurse and, where possible, the person's caretakers. The developmental dimension receives a salient attention of assessors. By introducing the developmental dimension in diagnostics and treatment, the bio-psycho-social dimensions are set in a new context, more appropriate for persons with ID. CONCLUSION: The integrative treatment should not be primarily directed towards the symptoms of the disorder but towards restoring a person's mental well-being. The disorder is combated through treatment of the underlying processes that have led to its onset. Different treatment methods from different perspectives may be applied. Strategy and methodological procedures of an integrative treatment are discussed by way of case presentations.

Applying the developmental perspective in the psychiatric assessment and diagnosis of persons with intellectual disability: part I--assessment.

BACKGROUND: In generic psychiatry there has been increasing interest among scientists for the developmental perspective. However, professionals active in the mental health care of people with intellectual disability (ID) have not shown the same degree of interest. The author of this article, who has had a liberal amount of rewarding experiences with the developmental approach in the field of ID, considers the developmental perspective to be innovative and very useful in psychiatric assessment, diagnosis and treatment of this population. The aim of the article is to stimulate a wider application of the developmental perspective as well as to challenge a professional discussion on this issue. METHODS: Basic assumptions of the developmental perspective are discussed and assessment tools and methods are described. RESULTS: In a case vignette, the advantages of developmentally based assessment are emphasized. Emotional development and personality development are viewed as the developmental components that play an important role in adaptive and maladaptive behaviour as well as in the onset and presentation of psychopathology. It is clear that interpretative insight into the totality of the psychosocial aspects of these individuals cannot only be obtained by measuring the level of cognitive development. A wider frame of mind is needed for unambiguous psychiatric diagnostics. Therefore, a replacement of the three dimensional paradigm (bio-psycho-social) by a four dimensional one (bio-psycho-socio-developmental) for the assessment and diagnosis of persons with ID is proposed.

Applying the developmental perspective in the psychiatric assessment and diagnosis of persons with intellectual disability: part II--diagnosis.

BACKGROUND: The descriptive phenomenological categorical psychiatric diagnostic systems that are currently being used in the field of intellectual disability do not adequately provide for the special needs of persons with intellectual disability. Many relevant diagnostic questions are left unanswered or are only partially accounted for. This is particularly true for persons with low developmental levels. METHOD: A solution to these stumbling blocks is sought in enhancing the contemporary categorical diagnostic systems by also applying methods derived from the developmental perspective. RESULT: By taking the levels of emotional and personality development, in addition to other developmental aspects into account, the clinical picture becomes more comprehensible and explainable. CONCLUSION: The integrative diagnosis that results from this combined approach provides an insight into the processes that have led to the disorder and enriches one's understanding of the presentation form of the disorder. This diagnosis is process- rather than symptom-oriented and is particularly useful with persons who have a low level of psychosocial development.

Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems.

BACKGROUND: During the last decade, there has been a growing interest in outpatient support services for persons with intellectual disability (ID) and psychiatric and/or behavioural problems and their families. In this study, we explore the family burden that is associated with children or adults with ID and behavioural or psychiatric problems living at home. METHOD: The research group consisted of 66 clients of In Casa, a project of outpatient treatment. Their average age is 18.97 years and their average IQ 55.37. The Reiss Screen for Maladaptive Behaviour (adults) or Reiss Scales for Children's Dual Diagnosis (children) and the Nijmegen Family Situation Questionnaire have been administered. RESULTS: About 62% of the children and 86% of the adults living at home and referred to In Casa have severe psychiatric or behavioural problems as measured by the Reiss scales. The dual diagnosis has a more negative impact on the family situation than the condition of ID only. CONCLUSION: Parents consider the psychiatric or behavioural problems of their child to be an extra burden and feel it more difficult to raise and manage such a child. This impels them to change the situation and to call on the help of external services. Some methodological questions and the implications of the findings in terms of support needs are discussed.

Simultaneous EEG and EDA measures in adolescent attention deficit hyperactivity disorder.

Adolescent unmedicated ADHD males and age- and sex-matched normal control subjects were examined simultaneously using EEG and EDA measures in a resting eyes-open condition. ADHD adolescents showed increased absolute and relative Theta and Alpha1 activity, reduced relative Beta activity, reduced skin conductance level (SCL) and a reduced number of non-specific skin conductance responses (NS.SCRs) compared with the control subjects. Our findings indicate the continuation of increased slow wave activity in ADHD adolescents and the presence of a state of autonomic hypoarousal in this clinical group.

Quantified EEG activity in adolescent attention deficit hyperactivity disorder.

The aim of this study was to explore elements of the maturational and cortical hypoarousal models in adolescent ADHD, by examining EEG activity in a rest eyes open condition, in 26 adolescent unmedicated ADHD males and 26 age and sex matched normal controls. ADHD adolescents were found to have increased anterior EEG absolute theta activity and reduced posterior relative beta activity compared with controls. These results lend some support to the continuation of a maturational lag and reduced cortical arousal in adolescent ADHD. These measures need to be further explored using concomitant EEG with electrodermal measures of arousal.

Diagnosis and treatment of psychiatric and behavioural disorders in mentally retarded individuals: the state of the art.

It is now well known that a higher proportion of people with mental retardation show behavioural and psychiatric disorders compared to their non-mentally retarded counterparts. However, the exact relationship between psychiatric illness and behavioural disorder in this population is far from clear. There are problems of using the standard diagnostic and classification categories in this population, particularly in those who are severely and profoundly mentally retarded. Recently, there have been many novel approaches to this diagnostic dilemma, including 'developmental approach' and 'psychodynamic approach'. In the Netherlands, the so-called 'developmental-dynamic' approach has been used in the diagnosis and treatment of behavioural and psychiatric disorders in the mentally retarded. There have also been many treatment approaches, including drug therapy, behavioural treatment, psychotherapy, cognitive and social learning. Also the Dutch, Swiss and German traditions have extensive experience in the directive pedagogical treatment of the mentally retarded.

Diagnosis and treatment of mental illness in mentally retarded children: a developmental model.

Attempts have been made in recent years to discover the roots of psychiatric disorders in mentally retarded children by employing a developmental approach in which the child, not the handicap, is brought more clearly into focus. This paper provides a brief overview of the developmental model that has proven useful for the author in the psychiatric diagnosis of mentally retarded children. Application of this model to the treatment of mentally ill-mentally retarded children is also addressed.

[Negative destructive behavior in young retarded children]. / Negatief-destructief gedrag bij geretardeerde peuters.

Twenty percent of a population of mentally retarded children, who underwent clinical observation because of behavior problems, demonstrated serious aggressive, destructive, negativistic and hyperactive behavior patterns. According to the parents this type of behavior developed between two and four years of age. It remains unclear whether this behavior is caused by a differential rate of maturation of certain brain structures or by unfavorable emotional and environmental variables. A psychotherapeutic approach to the treatment of these children led to positive results. It is supposed that if left untreated, a symptom shift can occur towards neurotic, depressive or aggressive behavior when the child gets older.

[Experiences with psychopharmaceutic agents in mentally retarded children]. / Ervaringen met psychopharmaca bij zwakzinnige kinderen.

There is little known about the influence that psychopharmaca have on the specific biological and psychic characteristics of the mentally retarded child, but still these drugs are frequently prescribed for the treatment of behavioral problems and psychic disturbances of mentally retarded children. Clinical drug therapy of behavioral and psychic disturbances of mentally retarded children is discussed based on personal experience and attitudes of the author. Psychopharmaca can be a useful adjunct to psychotherapy or related therapeutic approaches. The aim must not be to change the behavior totally through the use of psychopharmaca, but to eliminate certain symptoms which hinder the effect of psychotherapy. The duration of the drug therapy should be limited to a few months. The proper combination of psychotherapy and drug therapy makes the use of these drugs superfluous after a few months. Practical advice is given for the physician who treats mentally retarded children.